Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Reviews
Year : 2010 | Month : October | Volume : 4 | Issue : 5 | Page : 3255 - 3260

Fixed Dose Combination Antimicrobials Practices In Nepal – Review Of Literature

Kadir Alam1,2,3, Arjun Poudel1,4, Subish Palaian 1,2,4

1Department of Hospital and Clinical Pharmacy, Manipal Teaching Hospital, Pokhara, Nepal; 2Department of Pharmacology, Manipal College of Medical Sciences, Pokhara, Nepal; 3Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand; 4Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.

Correspondence Address :
Kadir Alam
Assistant Professor,
Department of Pharmacology
Manipal College of Medical Sciences
Pokhara, Nepal.
E-mail: alamkad2050@yahoo.com
Phone: 061-526420/526416 (Extn 221)

Abstract

Antibacterial drugs are one used commonly as fixed dose combination. The use of fixed dose combination antimicrobials is more common in developing countries. There are several studies which suggest extensive use of fixed dose combination antimicrobials drugs in Nepal. Although thousands of fixed dose combination are available in world market, WHO has approved only 25 fixed dose combination in 15th edition of WHO essential drug list. Even if some of the fixed dose antimicrobial offer some benefit in treatment of disease like Tuberculosis, Leprosy etc., majority of irrational fixed dose antimicrobials has major contribution in resistance development, decrease the flexibility of prescriber and increase the misuse by self-medication. To minimize the extensive use of fixed dose combination of antimicrobials certain measure like developing guideline for preparing of combination product, evaluation of product before registration, banning of irrational IFDC antimicrobials, strict monitoring, strict antibiotic policy, hospital antibiotic policy etc., will be helpful. In the developing world where resistance to antimicrobials is increasing, minimizing the use of irrational fixed dose combination antimicrobials can be better tool to combat with the resistance.

Introduction
Rational drug use means patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time and at the lowest cost to them and their community (1). Some of the common irrational drug use problems are polypharmacy, overuse of injections, self medication, misuse of antibiotics, use of irrational fixed dose combinations (IFDCs) etc. A fixed dose combination refers to the combination of two or more drugs in a single pharmaceutical formulation (2). The use of FDCs is common worldwide. Antibacterial drugs are one used commonly as fixed dose combination. Some of the commonly used irrational drug combinations include antibiotics combined with other antibiotics e.g. ampicillin + cloxacillin, antibiotic combination with antiamoebic e.g. ciprofloxacin + tinidazole etc. Irrational fixed dose combination in general and the need of intervention is already been described in a review article by Poudel A et al. (3) This article focuses mainly about the fixed dose combinations of antimicrobials in Nepal.
Fixed dose combination of antimicrobials practices in Nepal
Antimicrobials are grouped in class of drugs which can be dispensed only after the valid prescription from the registered medical practitioner. The relation between the use of antimicrobials and development of resistance is well established. Despite the established relation, the self-medication with the antibiotic is common in developing as well as developed countries (4), (5). The risk of resistance development is increased several fold by the use of irrational fixed dose combination. The use of fixed dose combination antimicrobials is more common in developing countries. There are several studies which suggest the extensive use of fixed dose combination antimicrobials drugs in Nepal. Some of studies showing extensive use of fixed dose of antimicrobials in Nepal are listed in (Table/Fig 1).
(Table/Fig 1): Studies suggesting the use of Fixed Dose Combination of Antimicrobials in Nepal

Fixed dose combination antimicrobials practice in developing countries
Studies showing extensive use of fixed dose of antimicrobials in developing countries are listed in (Table/Fig 2).
(Table/Fig 2): Studies suggesting the use of fixed dose combination of antimicrobials in developing countries

Fixed dose combination antimicrobials suggested by World Health Organization
Although there are thousands of fixed dose combinations that are available in world market. WHO has approved only 25 fixed dose combination in the 15th edition of WHO essential drug list. Fixed dose combination of antimicrobials approved in 15th edition of WHO essential drug list are mentioned in (Table/Fig 3).
(Table/Fig 3): FDC antimicrobials approved in WHO essential drug list 15th Edition (March 2007)

Fixed Dose Combination antimicrobials registered in Nepal
In Nepal, monitoring and evaluation of drugs starting from the production, marketing, distribution, export-import, storage to use of safe and efficacious drug is done by the Department of Drug Administration (DDA). Manufacturer has to register their individual product to the DDA before marketing their product. The list of registered antimicrobials in the DDA of Nepal is given in (Table/Fig 4).
(Table/Fig 4): List of fixed dose combination antimicrobials registered in the DDA of Nepal

Usefulness of Fixed Dose Combination antimicrobials
When two or more drugs are given together as like fixed dose combination, they may either be indifference to each other or produce synergism or antagonism. When the action of one drug is increased by another drug given concomitantly, it is said to be synergism and when one drug inhibit or decreases the action of another said to be antagonism. The synergistic actions produced by the fixed dose combination drug many remains beneficial for the treatment. Some of the synergistic action of fixed dose combination antibiotics is very much beneficial role in the treatment of infectious disease especially when resistant to single drug treatment is high. In addition, clinically the use of combinations of antimicrobials is advocated for empirical therapy when cause of infection is unknown, for treatment of multiple microbial infections, for synergistic action and to prevent the resistance (18). Examples of some of synergistic FDC antibiotics are listed in the (Table/Fig 5).
Moreover, the resistant to the treatment of disease like Tuberculosis, Leprosy is very high and is recommended to treat such disease with the multi-drug. In such condition, FDC antibiotics can decrease the complexity of dosage regimen, cost of therapy, incidence of ADR and increase the compliance of therapy.19 Thus decreases the resistance to the treatment.
(Table/Fig 5): Examples of some of synergistic FDC antimicrobials
Harmfulness of IFDC antimicrobials
Although some of the fixed dose antimicrobials offer some benefit in treatment of disease like Tuberculosis, Leprosy etc. The majority of irrational fixed antimicrobials have major contribution in resistance development. In addition, IFDC antimicrobials increase the toxicity and identification of causative drug in the combination (19). Moreover, the combination drug decreases the flexibility of prescriber and increase the misuse by self-medication.
Are all FDC antibiotics rational?
Rationality of fixed dose combination is always remains questionable. When it comes to antimicrobial, it may be rational sometimes but not always. Many irrational fixed dose combinations of antimicrobials are available. One of the examples is Ampicillin + Cloxacillin. None of the evidence supports the combination of these two drugs combinations (26). Moreover, there are so many other irrational combinations are available in the market. Some of them are Metronidazole + Tinidazole, Metronidazole + Diloxanate furate + Diphenhydramine, Doxycycline + Neomycine sulphate, Furazolidone + Metronidazole, Ofloxacin + Tinidazole, Ciprofloxacin + Metronidazole, Norfloxacin + Ornidazole, Tinidazole + Ciprofloxacin etc.
Strategies to minimize IFDC antimicrobials
The various strategies to minimize the IFDC antimicrobials are
1. Developing guidelines for preparing of combination product: Many irrational drugs get registered because of lack of guideline for combination products. Hence developing guideline for preparing fixed dose combination will be effective in minimizing irrational fixed dose combination of antimicrobials.
2. Evaluation of product before registration: The complete evaluation of fixed dose antimicrobials before registration will be helpful in minimizing irrational fixed dose combination antimicrobial.
3. Banning of irrational FDC antimicrobial: Banning of irrational fixed dose combination antimicrobials will be helpful in minimizing irrational fixed dose combination antimicrobial.
4. Strict monitoring of use of antimicrobial: Strict monitoring of specially fixed dose combination antimicrobials use can decrease the irrational fixed dose combination.
5. Strict antibiotic policy: Many countries have their antibiotic policy and the strict implementation of it has minimized the use of not only irrational fixed dose combination antimicrobials but also the use of antimicrobial and there was decrease in resistance.
6. Hospital antibiotic policy: In addition to antibiotic policy of the countries, many hospitals have their own antibiotic policy which monitors the use of antimicrobials at the hospital level. Hence the formation of hospital antibiotic policy to individual hospital may be helpful to minimize not only the use of IFDC antimicrobials also the excessive use of antimicrobial.
Initiatives to minimize the IFDC antibiotics in Nepal
In Nepal, some of the initiatives taken in the past to minimize the IFDC antimicrobials are
1. Banning of Irrational fixed dose combination antimicrobials: in the past DDA has banned several irrational fixed dose antimicrobial periodically (27). Some of them are
o Combinations of antihistamines with antidiarrhoeals or with antiamoebic
o Combinations of penicillin with sulfonamides
o Combinations of vitamins C with tetracycline
o Combinations of chloramphenicol except in combination with streptomycin
o Combinations of vitamins with antitubercular drugs except in combinations of antitubercular drug isoniazide with vitamin B6.
o Combination of Antidiarrhoeal/Antibacterial with Electrolytes
o Combination of Two or More Antibacterials Except the Following
o Combination Used for the Treatment of Tuberculosis
o Combination Used for the Treatment of Leprosy
o Combination of Two Antibiotics of the Penicillin Group
o Combination of Two or More Therapeutic Agents as Recognized by Standard Pharmacopoeia
o Combination of anti-amoebic or anti-diarrhoeal drug except the following
o Combination of Metronidazole or Tinidazole with Diloxanide furoate
o Combination of diphenoxylate 2.5mg with Atropine 0.025mg in a tablet
2. Re-evaluation of registered products: DDA re-evaluate the registered product time to time to find the harmful registered drugs, irrational combinations and drugs/combinations of doubtful therapeutic value (28). The evaluation is done by some of the NGO. Base on their recommendation DDA ban the harmful and irrational drugs. First time the drug was banned in 1983 followed by banning items in 1986, 1990, 1992 and 1997.
3. Incorporation of prudent use of antimicrobials in National Drug Policy (NDP): Although there is no separate antibiotic policy, Govt. of Nepal has added prudent use of antimicrobials in NDP as a one of the component under rational drug use which suggest about the supervision and monitoring of antimicrobial use to control the misuse of antimicrobial.
4.Drug Act 1978:Drug Act 1978 was brought into action which prohibits the misuse of drugs and also has categorized the antimicrobial into class of drug which can be sold only with prescription from the registered medical practitioner.

Conclusion

The misuse or over use of antimicrobial can lead to antimicrobial resistance. The use of irrational fixed dose combination antimicrobials can increase the antimicrobial resistance. To minimize the extensive use of fixed dose combination of antimicrobials certain measures like developing guidelines for manufacturing of combination products, evaluation of new products before registration, banning of IFDC antimicrobials, strict monitoring, strict antibiotic policy, hospital antibiotic policies etc., will be helpful. In the developing world where resistance to antimicrobial is increasing, minimizing the use of irrational fixed dose combination antimicrobials can be a better tool to combat antimicrobial resistance.

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